NCLEX-RN

Category - Basic Care

A nurse is assisting a client who just had a bronchoscopy due to a suspected infection in the lungs and bronchi. After the procedure, the client asks the nurse for a glass of water. The most appropriate action of the nurse is to:
  1. Elevate the head of bed and assist the client in drinking.
  2. Offer ice chips.
  3. Place a spoon on the back of the tongue and apply light pressure.
  4. Start with a clear-liquid diet.
Explanation
Answer: C - The appropriate action is to place a spoon on the back of the tongue and apply light pressure. This technique allows the nurse to check for the gag reflex. Before the procedure, local anesthesia is applied to relax the throat muscles. As the anesthesia wears off, the client’s throat may feel scratchy for a few days. The client should not be allowed to drink or eat anything until the return of the gag reflex.
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